Hearing Screening Form

Hearing Screening Form — Form Fields

This healthcare template includes 6 fields. Capture results and referral information from a hearing screening conducted in a clinical or community setting. Supports early identification of hearing loss in children and adults. Facilitates appropriate follow-up care and audiological assessment. Free to customize and use on ZenBuild.

• Patient Name (text, required)
• Date of Birth (text, required)
• Screening Method Used (dropdown selection, required) — options: Pure tone audiometry, OAE (Otoacoustic Emissions), ABR (Auditory Brainstem Response), Whisper test, Newborn hearing screen
• Screening Result (multiple choice, required) — options: Pass – both ears, Refer – one ear, Refer – both ears, Inconclusive – retest recommended
• Referral to audiologist recommended? (multiple choice, required) — options: Yes – urgent referral, Yes – routine referral, No – passed screening
• Clinician Notes (long text, optional)